Influence of surgical resection before and after chemotherapy on survival in small cell lung cancer

Prognostic factors of patients with small cell lung cancer after surgical treatment

Background

The current National Comprehensive Cancer Network guidelines recommend surgical treatment for patients with stages I–IIA small cell lung cancer (SCLC), but it still cannot deny the effect of surgical treatment on other limited-stage SCLC. Although more advanced diagnostic methods are now used for the diagnosis and classification of SCLC, the selection of surgical candidates is still arbitrary.

Methods

Data were collected from patients with SCLC who underwent surgery at the First Affiliated Hospital of Zhengzhou University from January 2011 to January 2021. Kaplan-Meier method was used to calculate cumulative survival curves, and log-rank test was used to evaluate differences among different subgroups. The Cox proportional hazard regression model was used to assess the predictive power of the variables for prognosis and survival.

Results

Smoking index, surgical resection method, TNM stage of postoperative pathology, and postoperative chemotherapy were significantly correlated with postoperative survival (P<0.05), which were independent predictors for postoperative survival. Patients with a smoking index >800 had a higher risk of death after surgery [hazard ratio (HR): 7.050, 95% confidence interval (CI): 3.079–16.143, P<0.001]. Compared with patients who underwent pulmonary lobectomy, those who underwent other pneumoresections (e.g., wedge resection, segmental resection, sleeve resection) had an increased risk of death (HR: 2.822, 95% CI: 1.030–7.734, P=0.044). Compared with stage I patients, stage II and stage III patients had an increased risk of death, with HRs of 6.039 and 3.145, respectively. Compared with those who received ≤4 courses of postoperative chemotherapy, those who received >4 courses of postoperative chemotherapy had reduced postoperative mortality risk (HR: 0.211, 95% CI: 0.097–0.459, P<0.001).

Conclusions

A high smoking index suggests worse prognosis; therefore, patients who smoke should be advised to quit smoking. Compared with stage II and stage III patients, surgical treatment is recommended for stage I SCLC patients. TNM staging, especially N staging, should be evaluated prior to surgery. Pulmonary lobectomy with mediastinal lymph node dissection should be the preferred surgical treatment for patients with SCLC. Patients should receive at least 5 courses of adjuvant chemotherapy after surgery.

[Surgery for small-cell lung cancer]

Small-cell lung cancer (SCLC) is a high-grade neuroendocrine carcinoma, metastatic at the time of initial diagnosis in 70% of cases. Within the 30% of localised tumours only 5% of patients are eligible for surgical treatment according to the recommendations of learned societies. These recommendations are mainly based on old phase II and III randomised prospective trials and more recent registry studies. Surgical care is only possible within a multimodal treatment and essentially concerns small-sized tumours without involvement of hilar or mediastinal lymph nodes. As with non-small cell lung cancer (NSCLC), lobectomy with radical lymph node removal is the recommended procedure to achieve complete tumour resection. Patient selection for surgery includes age, performance status and comorbidity factors. Adjuvant chemotherapy combining Platinum salts and Etoposide for resected stage I tumours is recommended by ASCO, ACCP and NCCN. The precise sequence of neo-adjuvant or adjuvant treatments remains controversial because of the large heterogeneity in clinical practice reported in the studies and the context at the time of SCLC discovery. The 5-year survival rate of patients with early stage disease (pT1-2N0M0) treated by lobectomy and adjuvant chemotherapy is between 30% and 58%, which validates the primary place that surgery must have in these early forms. There is certainly little or even no place for such a therapeutic sequence in locally advanced stages (T3-T4 or N2). However, the stage heterogeneity, as in NSCLC, makes final conclusions difficult. In fact, some registry studies with pairing scores reported a median survival of more than 20 months in N2 SCLC. So, all files of SCLC must be evaluated in a multidisciplinary meeting in order to find the optimal solution for patients with rare and heterogeneous tumours.

Surgery Plus Chemotherapy Versus Surgery Alone for Limited-Stage Small-Cell Lung Cancer: A Population-Based Survival Outcome Analysis

Introduction

For patients with limited-stage small-cell lung cancer (LS-SCLC), effective treatment methods still remain a clinical challenge. The aim of this study is to evaluate the survival outcome of surgery plus chemotherapy vs. surgery alone in patients with LS-SCLC.

Methods

LS-SCLC patients selected from the Surveillance, Epidemiology and End Results (SEER) database diagnosed between January 1, 2004, and December 31, 2015. Comparison of overall survival (OS) and cancer-specific survival (CSS) between two groups performed propensity score matching (PSM), inverse probability of treatment weight (IPTW), and overlap weighting analysis.

Results

Of the 477 LS-SCLC patients identified from the SEER database between 2004 and 2015, 262 (54.9%) received surgery-plus-chemotherapy treatment and the others received surgery-alone treatment. Univariate and multivariate analyses showed that treatment option (P< 0.001), tumor location (P= 0.02) and AJCC stage (P< 0.001) were independent prognostic predictors of OS in LS-SCLC patients. Median OS was 35 months in surgery-plus-chemotherapy group vs. 23 months in surgery-alone group. Survival analysis showed that surgery plus chemotherapy offered significantly improved OS as compared with surgery-alone treatment before and after IPTW, PSM and overlap weighting method (all P< 0.05). According to AJCC stage stratification, OS of the unmatched patients with stage I (P= 0.049) and II (P= 0.001) SCLC who received surgery-plus-chemotherapy treatment was significantly better than that of surgery-alone patients.

Conclusions

This cohort study showed that surgery plus chemotherapy was associated with longer survival time than surgery alone in LS-SCLC patients, especially in those with stage I and II SCLC. Further prospective studies are required to confirm our conclusions.

Role of surgery in a case-control study of patients with clinical stage IIIA small cell lung cancer

Background

The role of surgery in the multidisciplinary treatment of clinical stage IIIA small cell lung cancer is yet to be verified. This study was performed to determine the benefit of surgery in patients with stage IIIA small cell lung cancer.

Methods

Patients diagnosed with stage IIIA small cell lung cancer at Shanghai Pulmonary Hospital from 2005 to 2015 were included and divided into two groups: the surgery with neoadjuvant and adjuvant chemotherapy group and the concurrent chemo-radiotherapy group. Overall survival was compared between the two groups. A multivariate Cox regression model was constructed to evaluate factors associated with overall survival.

Results

Of 69 patients with stage IIIA small cell lung cancer during the study period, 40 patients (58%) underwent surgery with neoadjuvant and adjuvant chemotherapy, and 29 patients (42%) underwent concurrent chemo-radiotherapy. Patients in the surgery with neoadjuvant and adjuvant chemotherapy group had a longer overall survival compared with patients in the concurrent chemo-radiotherapy group (median survival: 33.1 vs. 16.2 months, respectively; 2-year overall survival: 44.2% vs. 14.9%, respectively; log-rank: P=0.045). A multivariate analysis revealed that surgery with neoadjuvant and adjuvant chemotherapy (hazard ratio: 0.374; 95% confidence interval: 0.173–0.808, P=0.012) was independently associated with overall survival.

Conclusions

Patients with stage IIIA small cell lung cancer treated with surgical resection plus chemotherapy demonstrated longer overall survival compared with those who underwent concurrent chemo-radiotherapy. Surgery may be an option for clinical stage IIIA small cell lung cancer after induction chemotherapy in selected patients.

Immune checkpoint inhibitors for treatment of small-cell lung cancer: a systematic review and meta-analysis

Background

Small cell lung cancer (SCLC) is a very aggressive and proliferative disease, with little progress being having made for its treatment in decades. Our goal was to evaluate the effect of immune checkpoint inhibitors (ICIs) and identify optimal first-line interventions for the treatment of SCLC.

Methods

A systematic literature search of the Cochrane Library, PubMed and oncology conference proceedings were conducted. Randomized trials evaluating ICIs for SCLC were included. We use the risk of bias tool in RevMan 5.3 to assess the quality of studies. We used Stata version 15.0 to carry out data direct comparison and R version 4.0.2 to conduct the Bayesian network analysis.

Results

A total of 16 relevant clinical trials comprising 4,476 patients were included. We found the magnitude of efficacy for ICIs as first-line therapy conferred a statistically significant benefit in overall survival (OS) and progression-free survival compared to chemotherapy alone. The results were 0.82 (95% CI, 0.76–0.89, P<0.001) and 0.80 (95% CI, 0.74–0.86, P<0.001). For objective response rate (ORR), the result (1.13, 95% CI, 0.97–1.31, P=0.109) was not significant. In the second-line and maintenance treatment, no additional benefit was observed. With regard to safety, results showed that for all grades of AEs and grades 3–4 AEs, the pooled results were 1.36 (95% CI: 0.50–3.70; P=0.543) and 1.35 (95% CI: 0.58–3.15; P=0.484) respectively. In addition, the indirect comparison results showed that nivolumab combined with chemotherapy led to the most significant improvement in OS, while durvalumab combined with chemotherapy was a more efficacious therapy for improving ORR compared with the other interventions; the probability were the best treatments was 73.93% and 81% respectively.

Discussion

Our results showed ICIs combined with etoposide and platinum-based drugs as first-line treatment of SCLC have benefits for patients and there was no evidence of a significant difference in efficacy among the different ICI drugs used for the first-line therapy. As for toxicity, the ICIs did not increase the frequency AEs for patients. However, as some studies are ongoing and the full data have still not been reported, our conclusions may not be completely representative.

Surgery in Small-Cell Lung Cancer

Simple Summary

Small-cell lung cancer (SCLC) accounts for approximately 15% of all lung cancers and is one of the most aggressive tumors, with poor prognosis and limited therapeutic options. This review summarizes the main results observed with surgery in SCLC, discussing the critical issues related to the use of this approach. Following two old randomized clinical trials showing no benefit with surgery, several prospective, retrospective, and population-based studies have demonstrated the feasibility of a multimodality approach including surgery in addition to chemotherapy and radiotherapy in patients with selected stage I SCLC. Currently, the International Guidelines recommend a surgical approach in selected stage I SCLC patients, after adequate staging within a multimodal approach and after a multidisciplinary evaluation.

Abstract

Small-cell lung cancer (SCLC) is one of the most aggressive tumors, with a rapid growth and early metastases. Approximately 5% of SCLC patients present with early-stage disease (T1,2 N0M0): these patients have a better prognosis, with a 5-year survival up to 50%. Two randomized phase III studies conducted in the 1960s and the 1980s reported negative results with surgery in SCLC patients with early-stage disease and, thereafter, surgery has been largely discouraged. Instead, several subsequent prospective studies have demonstrated the feasibility of a multimodality approach including surgery before or after chemotherapy and followed in most studies by thoracic radiotherapy, with a 5-year survival probability of 36–63% for patients with completely resected stage I SCLC. These results were substantially confirmed by retrospective studies and by large, population-based studies, conducted in the last 40 years, showing the benefit of surgery, particularly lobectomy, in selected patients with early-stage SCLC. On these bases, the International Guidelines recommend a surgical approach in selected stage I SCLC patients, after adequate staging: in these cases, lobectomy with mediastinal lymphadenectomy is considered the standard approach. In all cases, surgery can be offered only as part of a multimodal treatment, which includes chemotherapy with or without radiotherapy and after a proper multidisciplinary evaluation.

Prognosis of limited-stage small cell lung cancer with comprehensive treatment including radical resection

BACKGROUND

The NCCN (National Comprehensive Cancer Network) Clinical Practice Guidelines in Oncology (NCCN guidelines) recommend radical resection for T1-2N0M0 patients with limited-stage small cell lung cancer (LS-SCLC). However, only about 5% of patients with small cell cancer (SCLC) were initially diagnosed as T1-2N0M0. The purpose of our study was to analyze and compare the effects of the comprehensive treatment including radical surgery and concurrent chemoradiotherapy on the prognosis of patients with LS-SCLC.

METHODS

We comprehensively reviewed the medical data of patients with SCLC diagnosed by pathology in our hospital from January 2011 to April 2018. The Ethics Committee of West China Hospital of Sichuan University approved the study. Finally, 50 patients with good follow-up and complete medical data were selected as the surgical group (S group). According to the clinical characteristics of the patients in the S group, 102 LS-SCLC patients who received concurrent chemoradiotherapy in the same period were included in the CCRT group (concurrent chemoradiotherapy group) as the control group. Then according to the orders of the adjuvant treatments, the patients in the S group were divided into the SA group (radical surgery + adjuvant chemotherapy + adjuvant radiotherapy group, 30 cases in total) and the NS group (neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy group, 20 cases in total) for subgroup analysis. The SPSS 23.0 software was used for statistical analysis, and the t test was used for group comparison; Kaplan-Meier was used for survival analysis. P < 0.05 demonstrates a statistically significant difference.

RESULTS

The median progress-free survival (PFS) in the S group (73 months) was significantly better than that in the CCRT group (10.5 months, P < 0.0001), and the median overall survival (OS) in the S group (79 months) was also significantly better than that in the CCRT group (23 months, P < 0.0001). Subgroup analysis showed that there was no significant difference between the NS group and the SA group.

CONCLUSIONS

For LS-SCLC patients, the comprehensive treatment including radical surgery (radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy/neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy)may be superior to concurrent chemoradiotherapy.

The role of surgery in stage I to III small cell lung cancer: A systematic review and meta-analysis

Background

The role of surgery in treating small cell lung cancer (SCLC) remains controversial. This meta-analysis aims to determine whether surgical-based treatment improves survival in comparison to radiotherapy, chemotherapy, and chemoradiotherapy for stage I to III SCLC.

Methods

PubMed, PubMed Central, EMBASE, Web of Science, and Cochrane Library were searched for relevant articles. The main outcome were overall survival (OS), reported as hazard ratios (HRs), and 95% confidence intervals (CIs).

Results

Two randomized control trials (RCTs) and 13 retrospective studies that included a total of 41,483 patients were eligible. Surgical resection significantly improved OS when compared to non-surgical treatment in retrospective studies (HR = 0.56, 95% CI: 0.49–0.64, P < 0.001), but not in the 2 “older” RCTs (HR = 0.77, 95% CI: 0.32–1.84, P = 0.55). In the subgroup analysis for retrospective studies, surgical resection was associated with superior OS in stage I (HR = 0.56, 95% CI: 0.49–0.64, P < 0.001), stage II (HR = 0.75, 95% CI: 0.57–0.99, P = 0.04), and stage III diseases (HR = 0.70, 95% CI: 0.56–0.88, P = 0.002). Sublobar resection resulted in worse OS than a lobectomy (HR = 0.64, 95% CI: 0.56–0.74, P < 0.001) for patients undergoing surgical resection.

Conclusions

Surgery-based multi-modality treatment appears to be associated with a favorable survival advantage in stage I and selected stage II to III SCLC. Lobectomy is likely to provide superior OS when compared to sublobar resection. Further prospective RCTs are needed to confirm these findings.

Tumor size and lymph node metastasis are prognostic markers of small cell lung cancer in a Chinese population

Small cell lung cancer (SCLC) is a high-grade neuroendocrine tumor characterized by rapid growth, early metastatic spread, and poor prognosis. This study aimed to explore the prognosis factors of survival in Chinese SCLC patients.A total of 78 patients with stage IIIA SCLC (mean age: 53.9 years, 65 males and 13 females) were enrolled in this retrospective study. At least of 5 years follow-up was performed.The survival time of these patients ranged from 1 month to 66 months with a median survival time of 11 months. Kaplan-Meier method with log-rank test was performed and showed that survival time in patients with tumor size ≤4 cm (median: 16 months) was significantly longer (P < .001) than that in patients with tumor size > 4 cm (median: 8 months); the median survival time of the patients with single lymph node metastasis was significantly longer than that in patients with multiple lymph node metastasis (P = .043). Combined multiple lymph node metastasis and tumor size >4 cm presented the worst survival outcome than others. Multivariate analysis by Cox Hazard model shows that the lymph node metastasis and tumors size were prognostic factors independent of age, sex, smoke, surgery, and treatment regimen (P < .05).Results showed that larger tumor size and multiple lymph node metastasis were associated with the poor survival in SCLC.

Surgery for limited-stage small-cell lung cancer

BACKGROUND

Current treatment guidelines for limited-stage small-cell lung cancer (SCLC) recommend concomitant platinum-based chemo-radiotherapy plus prophylactic cranial irradiation, based on the premise that SCLC disseminates early, and is chemosensitive. However, although there is usually a favourable initial response, relapse is common and the cure rate for limited-stage SCLC remains relatively poor. Some recent clinical practice guidelines have recommended surgery for stage 1 (limited) SCLC followed by adjuvant chemotherapy, but this recommendation is largely based on the findings of observational studies.

OBJECTIVES

To determine whether, in patients with limited-stage SCLC, surgical resection of cancer improves overall survival and treatment-related deaths compared with radiotherapy or chemotherapy, or a combination of radiotherapy and chemotherapy, or best supportive care.

SEARCH METHODS

We performed searches on CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science up to 11 January 2017. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with adults diagnosed with limited-stage SCLC, confirmed by cytology or histology, and radiological assessment, considered medically suitable for resection and radical radiotherapy, which randomised participants to surgery versus any other intervention.

DATA COLLECTION AND ANALYSIS

We imported studies identified by the search into a reference manager database. We retrieved the full-text version of relevant studies, and two review authors independently extracted data. The primary outcome measures were overall survival and treatment-related deaths; and secondary outcome measures included loco-regional progression, quality of life, and adverse events.

MAIN RESULTS

We included three trials with 330 participants. We judged the quality of the evidence as very low for all the outcomes. The quality of the data was limited by the lack of complete outcome reporting, unclear risk of bias in the methods in which the studies were conducted, and the age of the studies (> 20 years). The methods of cancer staging and types of surgical procedures, which do not reflect current practice, reduced our confidence in the estimation of the effect.Two studies compared surgery to radiation therapy, and in one study chemotherapy was administered to both arms. One study administered initial chemotherapy, then responders were randomised to surgery versus control; following, both groups underwent chest and whole brain irradiation.Due to the clinical heterogeneity of the trials, we were unable to pool results for meta-analysis.All three studies reported overall survival. One study reported a mean overall survival of 199 days in the surgical arm, compared to 300 days in the radiotherapy arm (P = 0.04). One study reported overall survival as 4% in the surgical arm, compared to 10% in the radiotherapy arm at two years. Conversely, one study reported overall survival at two years as 52% in the surgical arm, compared to 18% in the radiotherapy arm. However this difference was not statistically significant (P = 0.12).One study reported early postoperative mortality as 7% for the surgical arm, compared to 0% mortality in the radiotherapy arm. One study reported the difference in mean degree of dyspnoea as -1.2 comparing surgical intervention to radiotherapy, indicating that participants undergoing radiotherapy are likely to experience more dyspnoea. This was measured using a non-validated scale.

AUTHORS' CONCLUSIONS

Evidence from currently available RCTs does not support a role for surgical resection in the management of limited-stage small-cell lung cancer; however our conclusions are limited by the quality of the available evidence and the lack of contemporary data. The results of the trials included in this review may not be generalisable to patients with clinical stage 1 small-cell lung cancer carefully staged using contemporary staging methods. Although some guidelines currently recommend surgical resection in clinical stage 1 small-cell lung cancer, prospective randomised controlled trials are needed to determine if there is any benefit in terms of short- and long-term mortality and quality of life compared with chemo-radiotherapy alone.

Stage-I small cell lung cancer: A new potential option for stereotactic ablative radiation therapy? A review of literature

Small cell lung cancer (SCLC) is relative rare histology in lung cancer patients. The standard treatment, in patients with an intra-thoracic disease, is represented by the use of concurrent chemo-radiotherapy; while patients with early SCLC stage, surgical resection could be recommended. Stereotactic body radiotherapy (SBRT) is a recently introduced technique allowing the delivery of very high radiation doses to limited target volumes and it is considered the standard approach in the treatment of not operable stage I Non Small-Cell Lung Cancer (NSCLC). The successful role option of SBRT in early NSCLC in terms of local control and toxicity profile opened the issue in the use of this approach in early stage small cell lung cancer (SCLC). Aim of this review is to discuss the current literature in the safety and efficacy of SBRT in the treatment of patients with stage I SCLC.

Prognostic Impact of Node-Spreading Pattern in Surgically Treated Small-Cell Lung Cancer: A Multicentric Analysis

OBJECTIVE

Although surgery in selected small-cell lung cancer (SCLC) patients has been proposed as a part of multimodality therapy, so far, the prognostic impact of node-spreading pattern has not been fully elucidated. To investigate this issue, a retrospective analysis was performed.

METHODS

From 01/1996 to 12/2012, clinico-pathological, surgical, and oncological features were retrospectively reviewed in a multicentric cohort of 154 surgically treated SCLC patients. A multivariate Cox proportional hazard model was developed using stepwise regression, in order to identify independent outcome predictors. Overall (OS), cancer-specific (CSS), and Relapse-free survival (RFS) were calculated by Kaplan-Meier method.

RESULTS

Overall, median OS, CSS, and RFS were 29 (95 % CI 18-39), 48 (95 % CI 19-78), and 22 (95 % CI 17-27) months, respectively. Lymphadenectomy was performed in 140 (90.9 %) patients (median number of harvested nodes: 11.5). Sixty-seven (47.9 %) pN0-cases experienced the best long-term survival (CSS: 71, RFS: 62 months; p < 0.0001). Among node-positive patients, no prognostic differences were found between pN1 and pN2 involvement (CSS: 22 vs. 15, and RFS: 14 vs. 10 months, respectively; p = 0.99). By splitting node-positive SCLC according to concurrent N1-invasion, N0N2-patients showed a worse CSS compared to those cases with combined N1N2-involvement (N0N2: 8 months vs. N1N2: 22 months; p = 0.04). On the other hand, the number of metastatic stations (p = 0.80) and the specific node-level (p = 0.85) did not affect CSS. At multivariate analysis, pN+ (HR: 3.05, 95 % CI 1.21-7.67, p = 0.02) and ratio between metastatic and resected lymph-nodes (RL, HR: 1.02, 95 % CI 1.00-1.04, p = 0.03) were independent predictors of CSS. Moreover, node-positive patients (HR: 3.60, 95 % CI 1.95-6.63, p < 0.0001) with tumor size ≥5 cm (HR: 1.85, 95 % CI 0.88-3.88, p = 0.10) experienced a worse RFS.

CONCLUSIONS

In selected surgically treated SCLC, the long-term survival may be stratified according to the node-spreading pattern.

Surgical results of resectable small cell lung cancer

Background

The standard of care for patients with small cell lung cancer (SCLC) is chemotherapy and radiotherapy, even for patients with limited disease. To define the role of surgical resection in patients with limited SCLC, we investigated the outcomes of patients diagnosed with limited-stage disease (LD) SCLC.

Methods

The records of 57 LD SCLC patients who underwent surgical resection from April 1974 to March 2012 were retrospectively analyzed.

Results

There were six women and 51 men, with a median age of 63.5 years. The overall five-year survival rate was 28.6% (median, 18.2 months). The p-stage II and III patients had a significantly worse survival than the p-stage I patients (13.4% vs. 43.4%, P = 0.0036). However, the c-stage was not found to correlate with survival. Patients who underwent pneumonectomy had a significantly worse outcome than those who underwent other surgical procedures (0.0% vs. 32.0%, P = 0.0002). In a multivariate Cox proportional hazards analysis, p-stage II or III (hazard ratio [HR] 3.040 P = 0.0017) and pneumonectomy (HR 6.177, P = 0.00159) were significant independent predictors of an adverse survival outcome.

Conclusions

Surgical treatment can be considered in SCLC patients with pathologically proven N0 status, although pneumonectomy should be avoided.

Is neoadjuvant chemotherapy mandatory for limited-disease small-cell lung cancer?

OBJECTIVES

The present study attempted to evaluate the role of neoadjuvant chemotherapy combined with surgery in limited-disease small-cell lung cancer (LD-SCLC).

METHODS

A retrospective analysis was performed on 106 LD-SCLC patients who underwent complete resections from February 2000 to February 2012 in Shanghai Pulmonary Hospital. Among these cases, two cycles of neoadjuvant chemotherapies were administered to all pathologically confirmed patients [Group Neoadjuvant (Group N)]. For those without pathology, operations followed by adjuvant chemotherapies were performed [Group Adjuvant (Group A)]. Prognostic features and overall survival (OS) were compared using the log-rank test and calculated using the Kaplan-Meier method.

RESULTS

Group N included 47 cases and Group A included 59 cases. A total of 57 patients were male and 49 were female, with a mean age of 56.1 ± 10.2 years. A total of 41 patients were at pathological stage (p-Stage) IIIa, and 65 patients were at I or II. The overall 5-year survival rate (5-YS) was 28%. The 5-YS for p-Stage I-II (n = 65) was significantly better than that of p-Stage III (n = 41) (35 vs 20%, P = 0.034). For p-Stage IIIa (pN2 positive), the 5-YS of Group N was significantly better than that of Group A (34 vs 12%, P = 0.020). The median overall survival for Group N and Group A in IIIa (pN2 positive) LD-SCLC patients were 46 and 15 months (P = 0.009), respectively. Multivariate analysis for survival showed mediastinal lymph node involvement; surgery and histopathology of SCLC were both significant independent predictors of long-term survival.

CONCLUSIONS

Neoadjuvant chemotherapy combined with surgery provided reasonable options for pIIIa-N2 LD-SCLC patients, which can give them a better chance of survival.

Evidence for management of small cell lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

PURPOSES

This systematic review addressed the following key questions on managing small cell lung cancer (SCLC): the sequence, timing, and dosing characteristics of primary thoracic radiotherapy (TRTx) for limited-stage disease; primary TRTx for extensive-stage disease; effect of prophylactic cranial irradiation (PCI); positron emission tomography (PET) for staging; treatment of mixed histology tumors; surgery; and second-line and subsequent-line treatment for relapsed/progressive disease.

METHODS

The review methods were defined prospectively in a written protocol. We primarily sought randomized controlled trials that compared the interventions of interest.

RESULTS

Robust evidence was lacking for all questions except PCI, for which a patient-level metaanalysis showed that PCI improves survival of SCLC patients who achieved complete response after primary therapy from 15.3 to 20.7% (p = 0.01). The case for concurrent over sequential radiation delivery rests largely on a single multicenter trial. Support for early concurrent therapy comes from one multicenter trial, but two other multicenter trials found no advantage. Metaanalysis did not find significant reductions in 2-year and 3-year mortality rates for early TRTx. Favorable results from a single-center trial on TRTx for extensive stage disease need replication in a multicenter setting. Relevant comparative studies were nonexistent for management of mixed histology disease and surgery for early limited SCLC. PET may be more sensitive in detecting extracranial disease than conventional staging modalities, but studies were of poor quality.

CONCLUSIONS

PCI improves survival among those with a complete remission to primary therapy. A research agenda is needed to optimize the effectiveness of TRTx and its components.

Should aggressive surgery ever be part of the management of small cell lung cancer?

CMT with surgery and chemotherapy is feasible, the toxicity is manageable, and postoperative morbidity and mortality rates are acceptable. Patient selection is important, and the results of the LCSG trial indicate that surgical resection will not benefit most patients who have limited SCLC. The chances of long-term survival and cure are strongly correlated with pathologic TNM stage. Consideration of surgery for patients who have SCLC should be limited to those with stage I disease and perhaps some patients with stage II tumors. Therefore, before surgery is undertaken, patients should undergo extensive radiologic staging with CT, MRI, and perhaps even positron emission tomographic scanning and mediastinoscopy, even if the radiologic assessment of the mediastinum is negative. Surgery may be considered for patients with T1-T2 NO SCLC tumors, and whether it is offered as the initial treatment or after induction chemotherapy remains controversial [40,43]. If SCLC is identified unexpectedly at the time of thoracotomy, complete resection and mediastinal lymph node resection should be undertaken, if possible. Chemotherapy is recommended postoperatively for all patients, even those with pathologic stage I tumors. Surgery likely has very little role to play for most patients with stage II disease and virtually no role for patients with stage III tumors. Even though chemotherapy can result in dramatic shrinkage of bulky mediastinal tumors, the addition of surgical resection does not contribute significantly to long-term survival for most patients, as shown conclusively by the LCSG trial. The final group of patients who may benefit from surgical resection are those with combined small cell and non-small cell tumors. If a mixed-histology cancer is identified at diagnosis, the initial treatment should be chemotherapy to control the small cell component of the disease, and surgery should be considered for the non-small cell component. For patients who demonstrate an unexpectedly poor response to chemotherapy, and for patients who experience localized late relapse after treatment for pure small cell tumors, a repeat biopsy should be performed. Surgery may be considered if residual NSCLC is confirmed.

Small cell lung cancer: from molecular biology to novel therapeutics

Small cell lung cancer (SCLC) is an aggressive tumor which metastasizes early. Patients with this disease have a poor prognosis even with immediate treatment. Because of the aggressive nature of this disease, all aspects of this tumor are studied extensively. This review will provide an update of the biology of SCLC at both the molecular and cellular levels. Cellular pathways and their relationship to cellular function will also be discussed. Treatment of both primary limited- and extensive-stage diseases as well as recurrent disease will be discussed including chemotherapy, thoracic radiotherapy, and surgery. The role of novel therapeutics being investigated will also be addressed.

New approaches for small-cell lung cancer: local treatments

BACKGROUND

Limited-disease small-cell lung cancer (LD-SCLC) can be cured with combinations of systemic chemotherapy and local treatments, predominantly radiation therapy. While systemic control inside the brain has been further improved with the inclusion of prophylactic cranial irradiation, long-term local control remains suboptimal, even with newer chemoradiation protocols.

METHODS

The authors review the current management of LD-SCLC and discuss strategies to improve local control. They present their own experience with the inclusion of surgery in an aggressive combined-modality protocol for patients with LD-SCLC.

RESULTS

Different approaches to improve local efficacy of treatment have been explored, including concurrent chemoradiation, administration of radiation as early as possible, newer fractionation schemas, and escalation of overall radiation doses. However, even following the currently most active chemoradiation protocols, local and locoregional relapse of LD-SCLC remains a problem. Surgery is feasible within this clinical setting and may add to long-term local control and possible cures.

CONCLUSIONS

Further investigation into the inclusion of surgery in LD-SCLC within carefully designed prospective clinical trials seems justified, although final evaluation would necessarily include prospective, randomized testing within a more "modernized" study design compared to the "old" and "historical" randomized Lung Cancer Study Group trial.

Surgical treatment of small cell lung cancer

Chemoradiotherapy remains a gold standard in the treatment of limited-disease small cell lung cancer. Currently, three indications for the surgical treatment of very limited disease (stage I, II, or highly selected IIIa) small cell lung cancer can be identified: (1) primary surgery in peripheral clinical N0 lesions followed by adjuvant chemotherapy or chemoradiotherapy; (2) primary chemotherapy or chemoradiotherapy followed by surgery +/- radiotherapy in patients with a good response to initial treatment; and (3) salvage operations in patients who recur or persist at the primary site but still have resectable disease. The value of these approaches has been assessed in retrospective analyses and prospective nonrandomized trials. A large prospective randomized trial failed to prove any added value for surgery in the multidisciplinary treatment of limited-disease small cell lung cancer, but very few very-limited-disease patients were included.

Small cell lung cancer I--III A: cytoreductive chemotherapy followed by resection with continuation of chemotherapy

OBJECTIVES

To define the place for surgery in combined modality treatment of small cell lung cancer patients. The endpoint was: does complete resection reduce the risk of local failure?

METHODS

Between November 1981 and June 1996, 75 patients in stage I--III A, many of them with a bulky cN2 tumor at presentation, were exposed to VP-16 based cytoreductive chemotherapy. After three courses of induction treatment, 46 patients underwent thoracotomy and 35 of them had resection.

RESULTS

There were two sudden deaths (pulmonary embolism). No other complications were observed. In six cases (6/35 = 16%), no residual tumor was found in the resected specimen. Four weeks after surgery, chemotherapy was resumed. Three patients experienced local relapse (3/33), among them, the single patient with incomplete resection, and two other patients developed local and distant failure (2/33). Thus, the local relapse rate was 15% (5/33). Eight patients, mainly with chemotherapy induced surgicopathological complete remission (pCR) and with lymph nodes free of tumor in surgical specimens (pN0), are alive, tumor-free, at a median of 136 + months. Two patients died tumor-free at 65 and 147 months. One patient died of unrelated causes at 21 months with no evidence of disease at autopsy. The median survival in the cN0 + N1 subsets was 25.09 months, whereas in cN2 disease, this was 13.75 months. There were no long-term survivors among the patients with persistent N2 disease. The median survival in all 35 patients using the Kaplan--Meier method was 18 months; the 5-year tumor-free survival rate was 29% and the 10-year tumor-free survival rate was 23%.

CONCLUSIONS

Satisfactory local tumor control confirmed the assumption of the study. No residual tumor in the resected specimen (pCR) is the most favorable prognostic factor and determinant of long-term survival. Surgery should not be performed in the patients with persistent N2 disease.

Surgical results for small cell lung cancer based on the new TNM staging system. Thoracic Surgery Study Group of Osaka University, Osaka, Japan

BACKGROUND

Operation with combined chemotherapy has been recently recommended for very early stage of small cell lung cancer without lymph node metastasis.

METHODS

A retrospective study was undertaken in 91 patients who had undergone pulmonary resection for small cell lung cancer according to the new international staging system.

RESULTS

The 5-year overall probability of survival was 37.1%. The 5-year survival rate was 100% for p-stage 0, 56.1% for p-stage IA, 30.0% for p-stage IB, 57.1% for p-stage IIA, and 42.9% for p-stage IIB. In the p-stage IA-IIB patients who underwent a complete resection, the 5-year survival rate of the patients treated by operation with chemotherapy was better than that of patients treated by operation alone. In addition, the 5-year survival rate of the patients who had four or more courses of chemotherapy was 80.0%.

CONCLUSIONS

These results suggest that operation should be considered for p-stage IA-IIB patients and more than four courses of combined chemotherapy might be desirable in these resectable cases.

Surgery in limited stage small cell lung cancer

The role of surgery in small cell lung cancer (SCLC) is controversial. Surgery has several potential advantages because it may reduce the frequency of local relapses, it does not impede the intensity of chemotherapy, it does not affect the bone marrow, and surgical staging may be of prognostic significance. Several smaller retrospective studies which focus on surgery alone, surgery with adjuvant chemotherapy or radiotherapy, or chemotherapy followed by adjuvant surgery have been reported. Five-year survival data have ranged from 10-50% according to stage, both T-status and nodal status appearing to be significant prognostic factors. Only one prospective randomized trial has been reported concerning the addition of surgery to chemotherapy alone. This trial does not favour surgery. The reason for this could be a selection bias in the smaller non-randomized studies or a result of stage migration. Nevertheless, surgery may yet play an important role in SCLC, especially in diagnosis and staging, and with new improved non-invasive staging procedures, such as positron emission tomography, resection may lead to cure in selected patients. Prospective randomized studies are needed to settle this issue.

Long term results of surgery and chemotherapy in small cell lung cancer

OBJECTIVE

The aim of the study is to analyse long-term results of patients with small cell lung cancer (SCLC) treated at the same institution according to a prospective study including surgery, chemotherapy, and radiotherapy.

METHODS

From 1981 to 1995, 104 patients with a proven histology of SCLC underwent surgery, chemotherapy, and radiotherapy. Fifty-one patients with operable stage I or II lesion received surgical resection followed by adjuvant chemotherapy and radiotherapy. Fifty-three patients with proved SCLC and clinical stage III received induction chemotherapy followed by surgery and radiotherapy. All patients received from four to six courses of chemotherapy and 36 had prophylactic cranial irradiation (PCI). All patients had follow-up for at least 1 year, and survival time was calculated from the date of the diagnosis until death or most recent follow-up.

RESULTS

Ninety-six patients were male and eight female. We performed 29 pneumonectomies, eight bilobectomies, 66 lobectomies and one no resection. Regarding the clinical stage, 35 patients (33.6%) had stage I, 16 patients (15.4%) had stage II and 53 (51%) had stage III. Post-operative pathologic staging revealed stage I in 37 patients (35.6%), stage II in nine patients (8.6%), stage III in 45 patients (43.3%), and in 13 patients (12.5%) there was no more tumor. The 30-day mortality was 2% (two patients). Fourteen patients (13.4%) had post-operative complications. Fifty-one patients (49%) had a relapse. The median follow-up was 55 months. Twenty-six patients remain alive and 78 patients have died. The overall 5-year survival rate was 32%, with an estimate median survival time of 28 months; according to the pathologic stage, the survival data were 52.2%, 30% and 15.3% for stage I, II and III, respectively (P < 0.001). The 5-year survival was 41% in patients without SCLC after chemotherapy.

CONCLUSION

As with non-small cell lung cancer, survival following surgery and chemotherapy clearly correlates with the stage. At present, it is not clear whether surgery is truly effective for patients with SCLC. In our experience, the complete elimination of small cell lung cancer is associated with an improvement in survival (41% at 5 years).

Surgery for small cell lung cancer

Operative management of small cell lung cancer generally yields little benefit because these tumors are known for their propensity to disseminate early to regional lymph nodes and distant sites. Primary surgery followed by chemotherapy is however indicated in very early stage tumors where survival approximates that of resected non small cell lung tumors. Surgery as an adjuvant to combination chemotherapy is also advocated by some authors to downstage the tumor and render it resectable. Candidates for salvage procedures include patients who have achieved complete response with chemotherapy, but subsequently relapsed within the chest at the site of the primary tumor.

A pilot phase 2 study of surgical treatment after induction chemotherapy for resectable stage I to IIIA small cell lung cancer

BACKGROUND

To evaluate the feasibility and efficacy of surgical resection of the primary tumor and regional lymph nodes in patients with resectable stage I to IIIA small cell lung cancer (SCLC) who had responded to induction chemotherapy.

METHODS AND RESULTS

Twenty-two patients (age, 39 to 70 years; median, 60.5 years) with resectable stage I to IIIA SCLC were identified as candidates for induction chemotherapy. All patients received two to four cycles of preoperative chemotherapy IV every 3 weeks (CAV II: cisplatin, 80 mg/m2, day 1; doxorubicin hydrochloride (Adriamycin), 30 mg/m2, day 1; etoposide (VePesid), 60 mg/m2 day 1 to 5). The overall response rate to induction chemotherapy was 95.5% (complete response, 5 of 22; and partial response, 16 of 22). After induction chemotherapy, 21 patients (95.5%) underwent a surgical resection (one pneumonectomy, 19 lobectomies, one segmentectomy). The postoperative pathologic study revealed only SCLC in 15 patients, only adenocarcinoma in one patient, and no residual tumor in five patients. The median survival time was 61.9 months for both the 21 surgical patients and all 22 patients, while their actuarial 3-year survival rates were 66.7% and 63.6%, respectively, for a follow-up period from 41.1 to 107.6 months (median, 59.8 months). Patients with clinical stages I and II disease had significantly longer survival times than did those with stage IIIA disease (3-year survival rates, 73.3% and 42.9%, respectively; p=0.018). The major adverse reaction was an operation-related death for one patient with N2 disease, but no other serious side effects were observed.

CONCLUSION

This induction chemotherapy followed by surgery is feasible and may be beneficial for the treatment of resectable stage I to IIIA SCLC.

Surgical treatment of small cell carcinoma of the lung: advantage of preoperative chemotherapy

To assess the effect of chemotherapy on postoperative survival of patients with small cell lung carcinoma (SCLC), 46 patients who underwent surgery at Kyoto University between 1976 and 1991 were retrospectively reviewed. Seventeen patients (37.0%) received chemotherapy prior to as well as after surgery (neoadjuvant therapy group), 23 (50.5%) received chemotherapy only after surgery (adjuvant therapy group), and the other six received no chemotherapy (non-chemotherapy group). The 5-year survival rate of patients with c-Stage I or II disease in the neoadjuvant therapy group was as high as 80.0%, which seemed to be higher, although with no statistical significance, than that in the adjuvant therapy group (37.7%, P = 0.10). The 5-year survival rate of patients with c-Stage III (IIIa or IIIb) disease in the neoadjuvant therapy group, although not satisfactory (10.0%), was significantly higher than that in the adjuvant therapy group (0.0%, P = 0.04). No patients in the non-chemotherapy group had survived 5 years. Moreover, multivariate analysis showed that failure to employ preoperative chemotherapy was the strongest prognostic factor causing a poor prognosis (P = 0.01). On the other hand, eight (30.8%) out of 26 patients with c-Stage I or II disease postoperatively proved to have mediastinal lymph node involvement (pN2-3), and two (7.7%) proved to have intrapulmonary metastasis (PM). Considering the advantage of preoperative chemotherapy and the discrepancy between c- and p-stage, sufficient chemotherapy prior to surgery should be employed, and may realize a good prognosis in patients with c-Stage I or II disease. In contrast, patients with c-Stage III disease are not appropriate as candidates for surgery even if preoperative chemotherapy is performed.

Surgery for cure followed by chemotherapy in small cell carcinoma of the lung. For the ISC-Lung Cancer Study Group

The Lung Cancer Study Group of the International Society of Chemotherapy (ISC-LCSG) organized multinational, cooperative, prospective and randomized trials for the cure of patients with small cell lung cancer at early stages (T1,2N0M0). Surgery for cure was used first, followed by postoperative chemotherapy, and thereafter by prophylactic cranial irradiation. Eight cycles of standard chemotherapy (CAV-cyclophosphamide-doxorubicin-vincristine) or 6 intermittent cycles of alternating chemotherapy, using 3 different drug combinations, were administered 1-2 weeks postoperatively for 6 months after randomization. A total of 183 evaluable patients received surgery for cure at 23 cooperating hospitals. The preliminary evaluation of ISC-studies I and II per May 1993 resulted in the 30-month total survival of 63% from 68 patients after complete resection at TN0M0R0-stages and 37% from 27 patients after such resections at TN2M0R0-stages. Their incidence of local recurrence as first relapse was quite similar (11/47:8/39). The related 4-year recurrence-free survival (57%, 37%), indicating a plateau-like curve of long-term survivors. These promising results have to be confirmed by larger studies. We conclude that the indication for surgery as the first treatment step for SCLC should be the same as for the other non-small subtypes of lung cancers.

The impact of surgery on the multidisciplinary treatment of bronchogenic small cell carcinoma (updated review including ongoing studies)

Recent results of studies on patients with SCLC treated by surgery with curative intent followed by adjuvant chemotherapy demonstrate a definite progress in comparison to non-surgical-treatment programs for patients with comparable stage of disease. Of 186 randomized patients enrolled for the multicenter cooperative ISC-Study I and II, 76 patients with stage pT1-3N0M0 received surgery for cure followed by chemotherapy and selective radiotherapy to the brain. The projected 4 year crude survival rate by September 1991 was 57%. In 27 of 43 patients with stage pT1-3N2M0, the tumors were completely resected, resulting in a 4 year survival rate of 32%. The survival curve for both groups of patients shows a sharp bent at 27 months postoperatively, whereafter the survival curves take a plateau-like course. These promising results were confirmed by several other groups. They are in favour of initial surgery for resectable tumors, followed by postoperative chemotherapy, while patients on preoperative chemotherapy followed by adjuvant surgery showed less favourable results.